Herbal Monograph
Elder
Sambucus nigra L.
Adoxaceae (formerly Caprifoliaceae)
Well-studied immune-supporting berry and traditional diaphoretic flower for respiratory health
Overview
Plant Description
Deciduous shrub or small tree, typically 3-6 m tall (occasionally reaching 10 m). Bark gray-brown, deeply furrowed and corky on older trunks; young branches green, smooth, with white pith. Leaves opposite, pinnately compound with 5-7 (rarely 9) leaflets, each 5-12 cm long, ovate to elliptic, serrate margins, dark green above, lighter below, producing a characteristic unpleasant odor when crushed. Flowers small (5-6 mm diameter), creamy white, five-petalled, strongly fragrant with a sweet muscat scent, borne in large flat-topped compound cymes (corymbs) 10-25 cm across, appearing June-July. Fruits globose drupes, 6-8 mm diameter, initially green, ripening to glossy deep purple-black in clusters, August-September. Each berry contains 3-5 small seeds.
Habitat
Hedgerows, woodland edges, scrubland, waste ground, riverbanks, and roadsides. Prefers moist, nitrogen-rich soils. Tolerates partial shade but fruits best in full sun. Adaptable to a wide range of soil types including alkaline and slightly acidic soils. Hardy in USDA Zones 4-8.
Distribution
Native throughout Europe, western Asia, and northern Africa. Naturalized in parts of North America, Australia, and New Zealand. Widely cultivated in Europe (especially Austria, Denmark, Germany) for commercial berry and flower production. S. nigra subsp. canadensis native to eastern and central North America.
Parts Used
Ripe berries (Sambuci fructus)
Preferred: Syrup; standardized extract (e.g., Sambucol); tincture of processed berries
The primary part used in modern elderberry preparations for immune support. Must be fully ripe (deep purple-black) and cooked or thermally processed before use. Raw berries contain cyanogenic glycosides (sambunigrin) and lectins (Sambucus nigra agglutinin) that can cause nausea, vomiting, and diarrhea. Cooking and commercial processing effectively degrade these compounds. Rich in anthocyanins, particularly cyanidin-3-glucoside and cyanidin-3-sambubioside.
Flowers (Sambuci flos)
Preferred: Infusion (tea); tincture; fresh or dried flowers
The primary part used in European traditional medicine, particularly as a diaphoretic for colds and fevers. Commission E positive monograph for elderflower as diaphoretic. EMA well-established use for the relief of early symptoms of the common cold. Contain flavonoids (rutin, isoquercitrin, hyperoside), phenolic acids (chlorogenic acid), triterpenes, mucilage, and essential oil (primarily fatty acids and monoterpenes). Generally considered safe without the cyanogenic glycoside concerns of raw berries.
Key Constituents
Anthocyanins (berries)
Total anthocyanin content ranges from approximately 500-1400 mg/100 g fresh weight in ripe berries depending on cultivar, growing conditions, and ripeness. Anthocyanins are responsible for the antioxidant, antiviral, and immunomodulatory activities attributed to elderberry. In vitro studies suggest anthocyanins inhibit viral replication by blocking hemagglutinin activity on influenza virus. Cyanidin-3-glucoside and cyanidin-3-sambubioside specifically demonstrated binding to H1N1 influenza virions in molecular docking studies (Roschek et al. 2009, PMID 19682714).
Flavonoids (berries and flowers)
Flavonoids contribute to the overall antioxidant, anti-inflammatory, and capillary-stabilizing effects of elderberry and elderflower preparations. Quercetin and its glycosides have documented anti-inflammatory activity through inhibition of NF-kB, COX-2, and lipoxygenase pathways. Rutin content is particularly high in flowers (up to 3% dry weight) and is used as a quality marker for Sambuci flos.
Phenolic acids
Phenolic acids contribute to the antioxidant capacity of elderberry preparations. Chlorogenic acid specifically has documented hypoglycemic and hepatoprotective effects in pharmacological studies. These compounds act synergistically with anthocyanins and flavonoids.
Lectins and proteins (raw berries)
These lectins are antinutritional and potentially toxic compounds that necessitate thermal processing of elderberries before consumption. They are effectively denatured at temperatures above 70-80C. Paradoxically, SNA has been investigated for potential anti-cancer activity in vitro due to its selective binding to sialic acid residues on cell surfaces, but this is a pharmacological research interest, not a therapeutic application.
Cyanogenic glycosides (raw plant material)
NOT therapeutically relevant -- this is a toxicological concern. Sambunigrin is the reason raw berries, bark, leaves, and stems must not be consumed. Cases of gastrointestinal distress, nausea, vomiting, and diarrhea have been reported from consumption of raw elderberries and elderberry juice that was inadequately processed. Proper cooking or commercial processing (heating above 80C) effectively destroys sambunigrin and the associated enzymes.
Essential oil and volatile compounds (flowers)
The volatile fraction of elderflower contributes to the sensory profile of infusions and cordials but is not considered a primary therapeutic component. Linalool has demonstrated mild anxiolytic and sedative properties in pharmacological studies.
Triterpenes and sterols
Triterpenes contribute to anti-inflammatory activity. Ursolic acid has demonstrated inhibition of NF-kB and COX-2 in vitro. These are considered minor contributors to the overall therapeutic profile relative to anthocyanins and flavonoids.
Vitamins and minerals (berries)
The vitamin C and mineral content of elderberry contributes to overall nutritional value but is not the primary basis of its therapeutic activity. The antioxidant capacity of elderberry far exceeds what can be accounted for by vitamin C content alone and is primarily attributable to anthocyanins and flavonoids.
Herbal Actions
Stimulates and enhances immune response
Elderberry preparations stimulate cytokine production (IL-1beta, TNF-alpha, IL-6, IL-8, IL-10) from monocytes, demonstrating immune-activating properties. Barak et al. (2001) showed that a standardized elderberry extract (Sambucol) increased inflammatory and anti-inflammatory cytokine production. Berry anthocyanins enhance NK cell and macrophage activity. Clinical trials demonstrate reduced duration and severity of influenza and upper respiratory infections, consistent with immunostimulant action.
[7, 8, 10]Prevents or slows oxidative damage to cells
Elderberry has one of the highest ORAC (Oxygen Radical Absorbance Capacity) values among commonly consumed fruits. The anthocyanin content provides potent free radical scavenging activity. Cyanidin-3-glucoside and cyanidin-3-sambubioside demonstrate strong DPPH and ABTS radical scavenging in vitro. The antioxidant capacity is significantly greater than that attributable to vitamin C content alone.
[17, 19]Promotes perspiration
Elderflower (Sambuci flos) is a classic diaphoretic in European herbal tradition, used to promote sweating during fevers and upper respiratory infections. This is the basis of the German Commission E positive monograph for elderflower. The diaphoretic action is attributed to the flavonoid and volatile oil content of the flowers. Traditionally combined with peppermint and yarrow in 'diaphoretic tea' formulas.
[1, 2, 13]Reduces inflammation
Both berry and flower preparations demonstrate anti-inflammatory activity. Elderberry anthocyanins inhibit pro-inflammatory cytokine production at physiologically relevant concentrations. Quercetin and rutin inhibit NF-kB, COX-2, and lipoxygenase pathways. In vitro studies show reduced production of nitric oxide and prostaglandin E2 by activated macrophages. Hawkins et al. (2019) meta-analysis noted reduced inflammatory markers as a consistent finding across supplementation studies.
[9, 17]Kills or inhibits the growth of microorganisms
In vitro antiviral activity demonstrated against influenza A and B viruses. Roschek et al. (2009) identified flavonoids that bind to H1N1 virions and block host cell entry. Elderberry extract inhibited replication of human pathogenic influenza viruses and avian influenza H5N1 and H7N7 in vitro (Konig 2014). Activity attributed to direct virion binding by anthocyanins and flavonoids rather than intracellular antiviral mechanisms. Some antibacterial activity against Gram-positive organisms reported in vitro.
[11, 12]Promotes the discharge of mucus from the respiratory tract
Elderflower has mild expectorant properties attributed to its mucilage and essential oil content. Used traditionally in combination with other herbs for productive coughs and bronchial congestion. Not a primary clinical indication in modern evidence-based practice.
[2, 13]Increases urine production and output
Elderflower infusion has traditionally been used as a mild diuretic. The EMA assessment notes traditional use for increased urinary output as an adjuvant in minor urinary tract complaints. The diuretic effect is considered mild and is attributed to the flavonoid content, particularly rutin and isoquercitrin.
[3, 13]Tightens and tones tissue, reduces secretions
Mild astringent properties attributed to tannin content. Contributing factor in traditional topical use for minor skin inflammation and gargling for sore throats.
[13]Therapeutic Indications
Immune System
Influenza -- treatment (reduced severity and duration)
Zakay-Rones et al. (2004) RCT: Sambucol elderberry extract significantly reduced duration of influenza symptoms by an average of 4 days compared to placebo. Hawkins et al. (2019) meta-analysis of 4 RCTs: elderberry supplementation significantly reduced upper respiratory symptoms (standardized mean difference -0.655, 95% CI -1.171 to -0.139, P=0.013). Effect appeared more pronounced for influenza than for the common cold. Tiralongo et al. (2016): reduced cold duration and severity in international air travelers.
[7, 8, 9]Common cold and upper respiratory infections -- treatment
Hawkins et al. (2019) meta-analysis found elderberry supplementation substantially reduced upper respiratory symptoms. Tiralongo et al. (2016) air traveler RCT showed significantly shorter cold duration (4.75 days vs 6.88 days) and reduced symptom severity in the elderberry group. The immune-stimulating mechanism (increased cytokine production) provides a plausible pharmacological basis.
[8, 9]Immune support during seasonal illness
Traditional use of both elderberry syrup and elderflower tea during cold and flu season for general immune support. NCCIH notes that elderberry may help with cold and flu symptoms but evidence is limited. Pharmacological basis supported by in vitro evidence of cytokine modulation and immunostimulant activity. No RCTs specifically for prevention; evidence is extrapolated from treatment trials and traditional use.
[6, 10, 13]Respiratory System
Febrile upper respiratory infections (elderflower -- diaphoretic)
Commission E positive monograph for elderflower (Sambuci flos) as a diaphoretic for the treatment of colds. EMA well-established use classification for elderflower: 'relief of early symptoms of common cold.' WHO monograph on Flos Sambuci supports traditional use as a diaphoretic. Dosage: 3-4 g elderflower per cup, 1-2 cups daily. One of the most well-established traditional uses with regulatory endorsement.
[1, 2, 3, 4]Sinusitis and upper respiratory congestion
Traditional use of elderflower for catarrhal inflammation of the upper respiratory tract. A proprietary combination product containing elderflower (Sinupret) has been studied in RCTs for acute sinusitis with positive results, but the contribution of elderflower specifically cannot be isolated from the multi-herb formula. Used traditionally as steam inhalation for sinus congestion.
[2, 13]Productive cough and bronchial congestion
Elderflower used traditionally as a mild expectorant in combination formulas for productive cough. Often combined with other respiratory herbs such as thyme, licorice, or white horehound. Limited specific clinical evidence for this indication.
[13]Cardiovascular System
Oxidative stress and cardiovascular risk factors
Anthocyanin-rich elderberry extracts demonstrate potent antioxidant activity and inhibition of LDL oxidation in vitro. A small pilot study (Curtis et al. 2009) explored anthocyanin supplementation for cardiovascular biomarkers. Epidemiological evidence supports dietary anthocyanin intake for cardiovascular risk reduction, but specific clinical trials on elderberry for cardiovascular outcomes are lacking.
[17]Skin / Integumentary
Minor skin inflammation and irritation (topical, elderflower)
EMA traditional use classification for elderflower applied topically: 'traditional herbal medicinal product for minor skin inflammations.' Elderflower water and compresses have been used traditionally for skin irritations, minor burns, and as a facial toner. The anti-inflammatory flavonoid content provides pharmacological plausibility.
[3]Urinary System
Minor urinary complaints (elderflower, adjuvant diuretic)
EMA traditional use classification notes elderflower for 'increasing the amount of urine to achieve flushing of the urinary tract as an adjuvant in minor urinary complaints.' Mild diuretic effect attributed to flavonoids. Not a primary indication; used as supportive therapy.
[3]Musculoskeletal System
Arthritis and rheumatic conditions
Traditional use of elderberry and elderflower for inflammatory joint conditions. In vitro evidence demonstrates anti-inflammatory activity of anthocyanins via inhibition of TNF-alpha and NF-kB. No clinical trials specifically evaluating elderberry for joint conditions. Classified as preliminary based on pharmacological plausibility and traditional use.
[13]Energetics
Temperature
cool
Moisture
slightly dry
Taste
Tissue States
hot/excitation, damp/stagnation
In Western herbal energetics, elderberry is classified as cool and slightly drying, making it well-suited for conditions of heat and damp stagnation -- particularly acute febrile infections with congestion. The berries are sweet and slightly sour with mild bitterness; the flowers are aromatic and slightly bitter. Elderflower is considered more cooling and diaphoretic than the berry, and is the preferred part for feverish conditions. The berry's cooling nature makes it appropriate for hot, inflamed conditions of the respiratory tract. Some practitioners describe elder as moving stagnant fluids, aligning with its traditional use as a mild diuretic and diaphoretic. CAVEAT: Herbal energetics are interpretive frameworks within Western herbalism, not standardized across all practitioners.
Traditional Uses
European folk medicine
- Elderflower tea (infusion) to promote sweating during fevers and colds
- Elderflower combined with peppermint and yarrow as 'diaphoretic tea' for acute febrile infections
- Elderberry syrup or rob (concentrated juice) for colds, coughs, and winter illness
- Elderflower water as a skin wash and complexion tonic
- Elderflower gargle for sore throats
- Elder bark decoction as a purgative and diuretic (historical; bark no longer recommended due to toxicity concerns)
- Elderberry wine and elderflower cordial as restorative tonics
- Elderflower poultice for chilblains and minor skin inflammations
"Hippocrates (circa 400 BCE) reportedly referred to the elder tree as his 'medicine chest,' though the attribution is apocryphal and cannot be traced to a specific Hippocratic text. The elder tree held a prominent place in European folk medicine for centuries, with virtually every part of the plant being used. John Evelyn (1664) wrote that if the 'medicinal properties of the leaves, bark, berries, etc. were thoroughly known, I cannot tell what our countrymen could ail for which he might not fetch a remedy from every hedge.'"
British herbal tradition
- Elderflower and peppermint tea for colds and influenza
- Elderberry rob (reduced juice) for winter coughs and sore throats
- Elderflower ointment (unguentum sambuci) for wounds, bruises, and skin conditions
- Elderflower water in cosmetic preparations
- Elderflower eyewash for conjunctivitis (historical)
"Nicholas Culpeper (1652) in The English Physician: 'The first shoots of the common Elder boiled like Asparagus, and the young leaves and stalks boiled in fat broth, doth mightily carry forth phlegm and choler.' The British Herbal Pharmacopoeia (1983) includes monographs for both elderflower and elderberry."
German/Central European phytotherapy
- Elderflower (Holunderbluten) as a diaphoretic tea for colds and febrile infections
- Elderflower as an ingredient in cough and cold tea blends
- Elderberry juice (Holundersaft) as a supportive remedy for colds and influenza
- Elderflower in combinations for sinusitis (as in the proprietary product Sinupret)
"The German Commission E issued a positive monograph for elderflower (Sambuci flos) in 1984 for use as a diaphoretic in the treatment of colds. Elderflower is one of the most commonly used herbal teas in Germany and Austria for cold and flu symptoms."
Native American (various traditions, S. canadensis)
- Bark and root tea as emetic and strong laxative (Iroquois, Menominee)
- Flower tea for fevers and headaches (Cherokee, Mohegan)
- Berry preparations as food and medicine (many tribes)
- Bark infusion for dropsy and urinary retention
- Flower poultice for skin conditions and swellings
"Native American medicinal use primarily involved Sambucus nigra subsp. canadensis (American elder). Uses varied by tribe and region. The Iroquois and Menominee used bark preparations as strong emetics and cathartics. Multiple tribes used flower preparations for fevers. Berry preparations were used both as food and medicine."
[16]
Modern Research
Elderberry extract (Sambucol) for influenza treatment
Randomized, double-blind, placebo-controlled trial of a standardized elderberry extract (Sambucol) in 60 patients aged 18-54 with influenza-like symptoms during an influenza B epidemic in southern Norway. Patients received 15 mL Sambucol or placebo syrup 4 times daily for 5 days.
Findings: Symptoms were relieved on average 4 days earlier in the elderberry group compared to placebo (3.1 +/- 1.3 days vs 7.1 +/- 2.5 days, P < 0.001). Complete resolution by day 3-4 in elderberry group versus day 7-8 in placebo. Use of rescue medication (analgesics/nasal sprays) was significantly lower in the elderberry group.
Limitations: Small sample size (n=60). Single site. Conducted during a known influenza B epidemic season, which may limit generalizability to influenza A. Industry involvement (Sambucol manufacturer). Symptom assessment was self-reported using visual analogue scales.
[7]
Elderberry supplementation for air travelers
Randomized, double-blind, placebo-controlled trial of 312 economy-class passengers traveling from Australia to an overseas destination. Participants received elderberry extract capsules (600-900 mg daily, standardized to anthocyanins) or placebo for 10 days before travel through 4-5 days after arrival.
Findings: No significant difference in cold incidence between groups. However, among those who did develop colds, the elderberry group had significantly shorter duration (4.75 days vs 6.88 days, P = 0.02) and lower symptom severity scores (sum of symptom score days 21 vs 34, P = 0.016). The reduction in cold episode days was statistically significant.
Limitations: Primary endpoint (cold incidence) was not significant. Sample size adequate for the primary endpoint but the secondary endpoints (duration, severity) showed benefit. Conducted among air travelers, a specific stress-related context. Self-reported symptoms.
[8]
Meta-analysis of elderberry supplementation for upper respiratory symptoms
Systematic review and meta-analysis of randomized controlled trials evaluating the effect of elderberry supplementation on upper respiratory symptoms. Included 4 RCTs with a total of 180 participants.
Findings: Elderberry supplementation was found to substantially reduce upper respiratory symptoms (standardized mean difference -0.655, 95% CI -1.171 to -0.139, P = 0.013). Effect was more pronounced in studies evaluating influenza than those evaluating the common cold. The authors concluded that elderberry may represent a potentially safer alternative to prescription medications for routine treatment of colds and influenza.
Limitations: Small total sample size across included trials (180 participants from 4 studies). Heterogeneity in preparations, dosing regimens, and outcome measures. Evidence graded as moderate quality. Additional large-scale RCTs are needed to confirm findings.
[9]
Elderberry extract and influenza virus neuraminidase inhibition
In vitro study evaluating the antiviral properties of a standardized elderberry extract against human influenza A (H1N1) virus using Madin-Darby canine kidney (MDCK) cell cultures and computational molecular docking analysis.
Findings: Elderberry extract flavonoids bound directly to H1N1 virions and blocked the ability of the virus to infect host cells. Two compounds (dihydromyricetin and a flavonoid related to 5,7,3',4'-tetra-O-methylquercetin) showed comparable activity to oseltamivir (Tamiflu) and amantadine in blocking viral infectivity. The mechanism involved direct binding to hemagglutinin on the viral surface.
Limitations: In vitro study only -- results cannot be directly extrapolated to clinical efficacy. Concentration-dependent effects may not be achievable in vivo. Molecular docking is a computational prediction that requires experimental validation.
[11]
Elderberry extract cytokine production
In vitro study investigating the effect of Sambucol elderberry extract on cytokine production by human monocytes. Sambucol and two of its formulations were tested against healthy donor blood monocytes.
Findings: Sambucol products activated healthy donors' monocytes and significantly increased production of inflammatory cytokines (IL-1beta, TNF-alpha, IL-6, IL-8) and the anti-inflammatory cytokine IL-10. The effect was 2-45 fold greater than that of lipopolysaccharide (a known potent monocyte activator for some cytokines). The authors proposed that the immunostimulatory properties could contribute to the antiviral activity observed in clinical trials.
Limitations: In vitro study using isolated monocytes, which may not reflect in vivo immune responses. The observation of increased inflammatory cytokine production raises theoretical concerns about potential for excessive immune activation, though this has not been observed clinically. Sponsored by Sambucol manufacturer.
[10]
Anti-influenza activity of elderberry against multiple strains
In vitro study testing elderberry liquid extract against multiple strains of influenza virus, including human H1N1, H3N2, influenza B, and highly pathogenic avian influenza H5N1 and H7N7.
Findings: Elderberry extract showed inhibitory activity against all tested influenza strains with IC50 values ranging from 252 +/- 34 mcg/mL to 478 +/- 47 mcg/mL. The antiviral activity appeared to be due to inhibition of viral glycoprotein function, preventing viral attachment and entry into host cells. Activity was demonstrated against both human seasonal and avian influenza strains.
Limitations: In vitro study. The concentrations needed for viral inhibition may not be achievable through oral supplementation. Avian influenza strains were tested in biosafety level 3 conditions and results cannot be extrapolated to human disease.
[12]
Anthocyanin bioavailability and pharmacokinetics
Narrative review examining the bioavailability, absorption, distribution, metabolism, and elimination of dietary anthocyanins including elderberry-derived cyanidin glycosides.
Findings: Anthocyanins are absorbed rapidly but with low absolute bioavailability (typically < 1% of ingested dose detected in plasma). Peak plasma concentrations occur within 1-2 hours of ingestion. Anthocyanins undergo extensive metabolism by gut microbiota, producing phenolic acid metabolites (protocatechuic acid, vanillic acid, hippuric acid) that may have independent biological activity. The biological effects of anthocyanins may be mediated as much by their metabolites as by the parent compounds.
Limitations: Review synthesized heterogeneous data from different anthocyanin sources. Bioavailability may differ between food matrix forms (whole berry, juice, extract). Individual variation in gut microbiome composition affects anthocyanin metabolism significantly.
[17]
Elderflower extract for rhinosinusitis (Sinupret combination)
Systematic review of the multi-herbal product Sinupret (containing elderflower, sorrel, cowslip, gentian root, and verbena) for the treatment of acute rhinosinusitis.
Findings: Multiple RCTs support the efficacy of Sinupret as an adjuvant to standard antibiotic therapy for acute rhinosinusitis. The combination product significantly improved symptoms and radiographic outcomes compared to placebo. However, the contribution of the elderflower component specifically cannot be isolated from the multi-herb combination.
Limitations: Evidence pertains to a multi-ingredient proprietary product, not elderflower alone. The individual contribution of each botanical ingredient is unclear. Most studies were conducted in Germany with potential cultural and prescribing pattern biases.
[18]
Preparations & Dosage
Syrup
Strength: Approximately 1:3 dried berry to finished syrup. Commercial standardized syrups: typically standardized to anthocyanin content (e.g., Sambucol original provides ~38% standardized elderberry extract per dose).
Elderberry syrup is the most popular modern preparation. Simmer 1 part dried elderberries (or 2 parts fresh, ripe, de-stemmed berries) in 2 parts water for 45-60 minutes until liquid is reduced by approximately half. Strain through cheesecloth, pressing berries to extract maximum juice. Allow to cool to below 40C, then add 1 part raw honey (for preservation and taste). Store refrigerated. Commercial syrups (e.g., Sambucol) use standardized extract with defined anthocyanin content.
15 mL (1 tablespoon) daily for maintenance; 15 mL every 2-3 hours at onset of symptoms for acute use (up to 60 mL/day for first 48 hours, then reduce to 15 mL 3-4 times daily)
1-4 times daily depending on acute or maintenance use
Acute use: 5-7 days or until symptoms resolve. Maintenance: throughout cold/flu season as desired.
Ages 2-5: 5 mL (1 teaspoon) 1-2 times daily. Ages 6-12: 5-10 mL 1-2 times daily. For acute use, frequency may be increased under practitioner guidance. Not recommended under age 2.
Most widely used form of elderberry. The Zakay-Rones 2004 RCT used Sambucol (standardized elderberry syrup) at 15 mL 4 times daily. Honey-based syrups should not be given to children under 1 year of age due to infant botulism risk (this is a honey concern, not an elderberry concern). Refrigerate after opening; homemade syrups typically last 2-3 months refrigerated.
Infusion (Tea)
Strength: 3-5 g dried elderflower per 250 mL water
Elderflower infusion: Place 3-5 g (approximately 2 teaspoons) of dried elderflowers in a cup. Pour 250 mL freshly boiled water over the flowers. Cover and steep for 10-15 minutes. Strain and drink while hot for diaphoretic effect. Can be combined with equal parts dried peppermint and/or yarrow for enhanced diaphoretic action.
1-2 cups (250-500 mL) 2-3 times daily
2-3 times daily; up to 5 times daily during acute febrile illness
Until symptoms resolve. Commission E: no specified duration limit for elderflower tea.
Ages 4-12: half adult dose. Not well-established for children under 4.
This is the traditional European preparation form and the basis of the Commission E positive monograph for elderflower. Must be drunk hot to achieve the diaphoretic effect -- cold infusion does not produce the same perspiration-inducing action. The classic 'flu tea' of European tradition combines equal parts elderflower, peppermint, and yarrow.
Tincture
Strength: Berry tincture: 1:5, 25-40% ethanol. Flower tincture: 1:5, 25% ethanol.
Berry tincture: Use thoroughly cooked/processed berries. Macerate 1 part processed berries in 5 parts menstruum (25-40% ethanol). Shake daily for 4-6 weeks. Strain and press. Flower tincture: Macerate 1 part dried elderflower in 5 parts menstruum (25% ethanol). Shake daily for 2-4 weeks. Strain and press.
Berry tincture: 3-5 mL three times daily. Flower tincture: 2-4 mL three times daily. For acute symptoms, dose may be taken every 2-3 hours for the first day.
Three times daily (maintenance); every 2-3 hours (acute, first 24-48 hours)
Acute use: 5-10 days. Seasonal maintenance: as directed by practitioner.
Not well-established; consult practitioner
Tinctures allow for convenient dosing and longer shelf life than syrups. Ethanol extraction captures both water-soluble and lipid-soluble constituents. Glycerites (vegetable glycerin-based) are available as alcohol-free alternatives, particularly for children.
Standardized Extract
Strength: Varies by product. Common standardization: 38% elderberry extract (Sambucol) or standardized to 2-4% anthocyanins. Some products standardized to specific cyanidin-3-glucoside content.
Commercial standardized extracts (e.g., Sambucol, Nature's Way Sambucus, etc.) are produced under controlled manufacturing conditions with defined levels of marker compounds, typically anthocyanins.
Product-specific. Sambucol original: 15 mL (1 tablespoon) 4 times daily for treatment (per Zakay-Rones 2004). Capsule/lozenge forms: typically 175-600 mg standardized extract per dose, 2-4 times daily. Tiralongo 2016 used 600-900 mg daily (capsule form).
2-4 times daily depending on product and indication
Treatment: 5-7 days. The Tiralongo 2016 trial used 10 days pre-travel through 4-5 days post-arrival safely.
Product-specific; follow manufacturer guidelines. Some products formulated specifically for children (e.g., Sambucol for Kids). Typical ages 2-12: reduced dosing per label.
Standardized extracts provide the most consistent dosing and are the form used in the strongest clinical evidence (Zakay-Rones 2004, Tiralongo 2016). Quality control ensures cyanogenic glycosides are below safety thresholds. When recommending elderberry, standardized products with clinical trial support are preferred.
capsule-powder
Strength: Varies by product. Capsules typically contain 500-1000 mg of dried fruit powder or concentrated extract.
Dried elderberry fruit or elderflower, powdered and encapsulated. Some products use freeze-dried berry powder to preserve anthocyanin content.
Dried berry powder: 500-1000 mg 2-3 times daily. Dried elderflower: 300-500 mg 2-3 times daily.
2-3 times daily
As directed by practitioner
Not well-established in capsule form for children
Capsules offer convenience and dosing precision. Anthocyanin content can degrade during processing and storage -- freeze-dried powders generally retain more active compounds than spray-dried or conventionally dried powders. Check for third-party quality verification (USP, NSF, ConsumerLab).
[8]
Glycerite
Strength: 1:3 to 1:5, vegetable glycerin
Alcohol-free preparation using vegetable glycerin as the extraction solvent. Suitable for children and those avoiding alcohol. Use processed berries: macerate 1 part cooked berries in 3-5 parts vegetable glycerin. May be gently heated (not exceeding 40C) to improve extraction. Steep 4-6 weeks.
5-10 mL three times daily
2-3 times daily
As directed by practitioner
Ages 2-5: 2.5 mL 1-2 times daily. Ages 6-12: 2.5-5 mL 1-2 times daily.
Glycerites are popular for pediatric use due to the naturally sweet taste and absence of alcohol. Glycerin extracts anthocyanins and flavonoids less efficiently than ethanol, so effective doses may need to be higher. Shelf life is typically shorter than tinctures (1-2 years vs 3-5 years).
[13]
Safety & Interactions
Class 1
Can be safely consumed when used appropriately (AHPA Botanical Safety Handbook)
Contraindications
Raw elderberries contain cyanogenic glycosides (sambunigrin) and lectins (SNA) that cause nausea, vomiting, abdominal cramps, diarrhea, and weakness. The CDC documented an outbreak in 1983 where 8 people became ill after drinking raw elderberry juice. Bark and leaves contain substantially higher concentrations of sambunigrin. All elderberry preparations must use properly processed (cooked or heated) berries. This is a raw plant material concern, not a concern for properly prepared commercial products or cooked preparations.
Allergic reactions are rare but possible. Individuals with known allergy to elderberry or elderflower should avoid use.
Drug Interactions
| Drug / Class | Severity | Mechanism |
|---|---|---|
| Immunosuppressants (cyclosporine, tacrolimus, azathioprine, mycophenolate, corticosteroids) (Immunosuppressants) | theoretical | Elderberry stimulates cytokine production (IL-1beta, TNF-alpha, IL-6, IL-8) and activates monocytes. Theoretically, this immunostimulant activity could counteract the effects of immunosuppressive medications. |
| Antidiabetic medications (metformin, sulfonylureas, insulin) (Hypoglycemics) | theoretical | Elderberry has demonstrated modest insulin-like and insulin-secretagogue activity in in vitro studies. Theoretically, concurrent use could potentiate hypoglycemic effects. |
| Diuretics (thiazides, loop diuretics) (Diuretics) | minor | Elderflower has mild diuretic properties. Concurrent use with pharmaceutical diuretics could theoretically produce an additive effect. |
| Theophylline (Methylxanthines) | minor | Elderberry has demonstrated mild CYP1A2 inhibition in vitro, which could theoretically slow theophylline metabolism. |
Pregnancy & Lactation
Pregnancy
insufficient data
Lactation
insufficient data
No clinical studies of elderberry or elderflower use during pregnancy or lactation. Elderflower has a long history of traditional use during pregnancy in European folk medicine as a tea for colds. The German Commission E monograph does not list pregnancy as a contraindication for elderflower. The AHPA Botanical Safety Handbook classifies S. nigra flower as 'no special precautions' (Class 1) and does not list a pregnancy-specific restriction for properly prepared products. However, formal safety data in pregnant or lactating women is lacking. Prudent to advise consulting a healthcare provider before use during pregnancy and lactation.
Adverse Effects
References
Monograph Sources
- [1] German Commission E (Bundesinstitut fur Arzneimittel und Medizinprodukte). Commission E Monograph: Sambuci flos (Elderflower) -- Positive. Bundesanzeiger (Federal Gazette) (1984)
- [2] Blumenthal M, Busse WR, Goldberg A, Gruenwald J, Hall T, Riggins CW, Rister RS (eds.). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. American Botanical Council, Austin, TX (1998) . ISBN: 978-0965555500
- [3] Committee on Herbal Medicinal Products (HMPC), European Medicines Agency. European Union Herbal Monograph on Sambucus nigra L., flos. European Medicines Agency (2013)
- [4] World Health Organization. WHO Monographs on Selected Medicinal Plants, Volume 2: Flos Sambuci. World Health Organization, Geneva (2002) : 269-275
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Clinical Studies
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Traditional Texts
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Pharmacopeias & Reviews
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- [20] Centers for Disease Control and Prevention. Poisoning from elderberry juice -- California. MMWR Morb Mortal Wkly Rep (1984) ; 33 : 173-174
Last updated: 2026-02-26 | Status: review